Method for closing wound

ABSTRACT

A method for closing a wound in a tubular organ using a suture thread includes: a first step of connecting a first edge portion and a second edge portion with the suture thread; and a second step of connecting a third edge portion and a fourth edge portion with the suture thread. The first step includes passing the suture thread through a first position on a mucosal surface of at least one of the first edge portion and the second edge portion. The second step includes passing the suture thread through a third position on the mucosal surface of at least one of the third edge portion and the fourth edge portion. A shortest distance between the wound and the third position is larger than a shortest distance between the wound and the first position.

CROSS-REFERENCE TO RELATED APPLICATIONS

This is a Continuation of U.S. patent application Ser. No. 17/585,135filed Jan. 26, 2022, which in turn claims priority from U.S. PatentApplication No. 63/154,908, filed on Mar. 1, 2021. The disclosure of theprior applications is hereby incorporated by reference herein in itsentirety.

BACKGROUND Technical Field

The present disclosure relates to a method for closing a wound.

Background

Conventionally, a technique of transendoscopically closing a part(wound) where the mucosa in a tubular organ such as the digestive tractis defective by ESD (endoscopic submucosal dissection) has beenperformed. For example, a method is known for closing a portion (wound)in which a mucous membrane is defective under observation with anendoscope by using a suture thread device, a needle holder, a clipdevice, or the like. A wound closing method that can effectively closethe wound even when the mucosal defect (wound) is large is desired.

A known suturing method uses a suture thread device and an endoscope tocontinuously sutured tissue without taking the suture thread deviceintroduced into the patient's body out of the body. The tissue openingis closed by inserting a suture needle into the edge of the tissueopening and passing the suture thread through the edge.

SUMMARY

A first aspect of the present disclosure is a method for closing a woundin a tubular organ using a suture thread. A peripheral edge of the woundincludes a first edge portion, a second edge portion located oppositethe first edge portion across the wound, a third edge portion adjacentto the second edge portion, and a fourth edge portion located oppositethe third edge portion across the wound. An opening of the wound islargest between the third and fourth portions such that a distancebetween an edge-end of the third edge portion and an edge-end of thefourth edge portion is a maximum distance between edges of the wound.The method includes: a first step of connecting the first edge portionand the second edge portion with the suture thread, including passingthe suture thread through a first position on a mucosal surface of atleast one of the first edge portion and the second edge portion; and asecond step of connecting the third edge portion and the fourth edgeportion with the suture thread, including passing the suture threadthrough a third position on the mucosal surface of at least one of thethird edge portion and the fourth edge portion. A shortest distancebetween the wound and the third position is larger than a shortestdistance between the wound and the first position.

In a second aspect, a method for closing the wound includes: a firststep of connecting the first edge portion and the second edge portionwith the suture thread, including passing the suture thread through afirst position on a mucosal surface of at least one of the first edgeportion and the second edge portion and a second position on the mucosalsurface away from the first position; and a second step of connectingthe third edge portion and the fourth edge portion with the suturethread, including passing the suture thread through a third position onthe mucosal surface of at least one of the third edge portion and thefourth edge portion and a fourth position on the mucosal surface awayfrom the third position. In this method, a second distance between thethird position and the fourth position is smaller than a first distancebetween the first position and the second position.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a diagram showing an endoscope and a needle holder used in awound closing method according to an exemplary embodiment.

FIG. 2 is an overall view showing the needle holder.

FIG. 3 is a perspective view showing a grip portion of the needleholder.

FIG. 4A is a diagram showing an insertion portion of the endoscopeintroduced into a gastrointestinal tract.

FIG. 4B is a diagram showing an insertion step when a tubular organ is astomach.

FIG. 4C is a diagram showing an insertion step when the tubular organ isa large intestine.

FIG. 5 is a top view of the insertion portion arranged to close thewound.

FIG. 6 is a diagram showing step A-1 in the wound closing method.

FIG. 7 is a cross-sectional view of the wound orthogonal to a depthdirection in step A-1.

FIG. 8 is a diagram showing step A-2 in the wound closing method.

FIG. 9 is a cross-sectional view of the wound orthogonal to the depthdirection in step A-2.

FIG. 10 is a diagram showing step B-1 in the wound closing method.

FIG. 11 is a cross-sectional view of the wound orthogonal to the depthdirection in step B-1.

FIG. 12 is a diagram showing step B-2 in the wound closing method.

FIG. 13 is a cross-sectional view of the wound orthogonal to the depthdirection in step B-2.

FIG. 14 is a diagram showing a first suturing step in the wound closingmethod.

FIG. 15 is a diagram showing step C-1 in the wound closing method.

FIG. 16 is a diagram showing step C-2 in the wound closing method.

FIG. 17 is a diagram showing step D-1 in the wound closing method.

FIG. 18 is a diagram showing step D-2 in the wound closing method.

FIG. 19 is a diagram showing step E-1 in the wound closing method.

FIG. 20 is a diagram showing step E-2 in the wound closing method.

FIG. 21 is a diagram showing step F-1 in the wound closing method.

FIG. 22 is a diagram showing step F-2 in the wound closing method.

FIG. 23 is a diagram showing a second suturing step in the wound closingmethod.

FIG. 24 is a diagram showing a suture thread passed through the wound.

FIG. 25 is a diagram showing another aspect of the wound closing method.

FIG. 26 is a diagram showing another aspect of the wound closing method.

FIG. 27 is a diagram showing a modified example of the wound W.

FIG. 28 is a diagram showing another modified example of the wound W.

FIG. 29 is a diagram showing the suture thread passed through the woundby the wound closing method according to an exemplary embodiment.

FIG. 30 is a diagram showing a modified example of the wound W.

FIG. 31 is a diagram showing another modified example of the wound W.

FIG. 32 is a diagram showing the wound after a third step in the woundclosing method.

FIG. 33 is a diagram showing a reinforcement step.

FIG. 34 is a diagram showing a modified example of the reinforcementstep.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

A wound closing method according to an exemplary embodiment of thepresent disclosure will be described with reference to FIGS. 1 to 24 .FIG. 1 is a diagram showing an endoscope 200 and a needle holder 100used in the wound closing method according to the present embodiment.

[Endoscope 200]

The surgeon can use a known endoscope that is orally inserted into atubular organ such as a gastrointestinal tract. As shown in FIG. 1 , theendoscope 200 used in the present embodiment includes an insertionportion 202 inserted into a body from a distal end and an operationportion 207 attached to a proximal end of the insertion portion 202.

The insertion portion 202 has an imaging portion 203, a curved portion204, and a flexible portion 205. The imaging portion 203, the curvedportion 204, and the flexible portion 205 are connected in order fromthe distal end of the insertion portion 202. A channel 206 for insertingthe needle holder 100 is provided inside the insertion portion 202. Adistal end opening 206 a of the channel 206 is provided at the distalend of the insertion portion 202.

The imaging portion 203 includes, for example, a CCD or CMOS, and canimage a portion to be treated. The imaging portion 203 can image a gripportion 3 of the needle holder 100 in a state where the needle holder100 protrudes from the distal end opening 206 a of the channel 206. Thecurved portion 204 can be bent according to the operation of theoperating portion 207 by the surgeon. The flexible portion 205 is aflexible tubular portion.

The operation portion 207 is connected to the flexible portion 205. Theoperation portion 207 has an input portion 209 and a proximal endopening 206 b of the channel 206. The input portion 209 receives anoperation input for bending the curved portion 204.

[Needle holder 100]

FIG. 2 is an overall view showing the needle holder 100.

The needle holder 100 includes a sheath 1, a hard portion 2, a gripportion 3, an operation portion 4, and an operation wire 5 (see FIG. 3 )inserted through the sheath 1. The needle holder 100 is used byinserting it into the channel 206 of the endoscope 200.

The sheath 1 is a flexible member that extends from a distal end 1 a toa proximal end 1 b. As shown in FIG. 1 , in a state where the sheath 1is inserted into the channel 206, the distal end 1 a of the sheath 1 canbe recessed from the distal end opening 206 a of the channel 206. Asshown in FIG. 2 , the distal end 1 a of the sheath 1 is provided withthe hard portion 2. The operation portion 4 is provided at the proximalend 1 b of the sheath 1.

FIG. 3 is a perspective view showing the grip portion 3 of the needleholder 100.

The grip portion 3 has a first grip member 31, a second grip member 32,and a link mechanism 36. The first grip member 31 and the second gripmember 32 are configured to be openable and closable.

The first grip member 31 is a part of the distal end portion of the hardportion 2. The first grip member 31 extends along the longitudinal axisA of the sheath 1. The second grip member 32 is connected to the hardportion 2 so as to be openable and closable with respect to the firstgrip member 31.

As shown in FIG. 2 , the operation portion 4 has a main body 40 and aslider 41. The slider 41 is connected to the main body 40 so as to beable to move forward and backward, and can move forward and backwardalong the axial direction of the main body 40. The operation wire 5extending from the sheath 1 passes through the inside of the main body40 and is connected to the slider 41.

As shown in FIG. 3 , the operation wire 5 is arranged inside the sheath1 along the longitudinal axis A of the sheath 1. The surgeon can movethe operating wire 5 forward and backward along the longitudinal axis Aof the sheath 1 by moving the slider 41 forward and backward along themain body 40. The surgeon can pull the operation wire 5 toward theoperation portion 4 by moving the slider 41 toward the proximal end sidealong the main body 40.

When the operation wire 5 is pulled toward the operation portion 4, thesecond grip member 32 moves in the closing direction with respect to thefirst grip member 31. On the other hand, when the operation wire 5 ispushed toward the grip portion 3, the second grip member 32 moves in theopening direction with respect to the first grip member 31.

[Closing the Wound]

Next, the wound closing method (method of using the needle holder 100)according to the present embodiment will be described with reference toFIGS. 4A to 24 . Specifically, a procedure for closing a portion (woundW) in which the mucosa of the digestive tract is defective by ESD(endoscopic submucosal dissection) treatment will be described. Thewound closing method according to the present embodiment is not limitedto a wound in the digestive tract, and can be applied to a wound in atubular organ.

Before inserting the endoscope 200 into the gastrointestinal tract, thesurgeon protrudes the grip portion 3 of the needle holder 100 from thedistal end opening 206 a of the channel 206 of the endoscope 200. Thesurgeon grips the suture needle N with the grip portion 3. The sutureneedle N used in this embodiment is a curved needle. The treatment toolused in the wound closing method according to the present embodiment isnot limited to the needle holder 100, and may be a treatment toolcapable of gripping the suture needle N.

[Insert step]

FIG. 4A is a diagram showing an insertion portion 202 of the endoscope200 introduced into the gastrointestinal tract.

In the insertion step, the surgeon inserts the endoscope 200 into thegastrointestinal tract through the patient's natural opening. Theinsertion portion 202 is introduced into the digestive tract with thesuture needle N gripped by the grip portion 3 protruding from the distalend opening 206 a. FIG. 4B is a diagram showing the insertion step whenthe tubular organ is the stomach St. The right side of FIG. 4B is across-sectional view of the stomach St. Further, FIG. 4C is a diagramshowing the insertion step when the tubular organ is the large intestineCl.

[Placement Step]

FIG. 5 is a top view of the insertion portion 202 arranged for closingthe wound W.

In the placement step, the surgeon determines a first facing edgeportion O1 and a second facing edge portion O2 to be brought closethrough the suture thread S to close the wound W. The first facing edgeportion O1 and the second facing edge portion O2 are edge portionsforming the peripheral edge of the wound W. The first facing edgeportion O1 and the second facing edge portion O2 are at positions facingeach other with the wound W sandwiched between them.

In the following description, the direction in which the first facingedge portion O1 and the second facing edge portion O2 face each other isalso referred to as “width direction D1 of the wound W”. Further, thedirection along the wound W and perpendicular to the width direction D1is also referred to as “depth direction D2 of the wound W”.

The surgeon arranges the distal end of the insertion portion 202 of theendoscope 200 so that the grip portion 3 protruding from the insertionportion 202 of the endoscope 200 passes between the first facing edgeportion O1 and the second facing edge portion O2. As a result, thesuture needle N gripped by the grip portion 3 of the needle holder 100is arranged at a position where it can easily be inserted into the firstfacing edge portion O1 and the second facing edge portion O2.

The first facing edge portion O1 has a first edge portion E1, a fourthedge portion E4, and a fifth edge portion E5. The first edge portion E1,the fourth edge portion E4, and the fifth edge portion E5 are regionsextending along the depth direction D2. The first edge portion E1 andthe fourth edge portion E4 are adjacent to each other, and the fourthedge portion E4 and the fifth edge portion E5 are adjacent to eachother. The first edge portion E1 is located, for example, proximal tothe endoscope 200 from the fourth edge portion E4. In that case, thefifth edge portion E5 is located distal to the endoscope 200 from thefourth edge portion E4.

On the wound W side of the first edge portion E1, an edge-end T1, whichis a cut surface caused by a tissue defect, is formed. Further, anedge-end T4, which is a cut surface generated by a tissue defect, isformed on the wound W side of the fourth edge portion E4. Further, anedge-end T5, which is a cut surface generated by a tissue defect, isformed on the wound W side of the fifth edge portion E5.

The second facing edge portion O2 has a second edge portion E2, a thirdedge portion E3, and a sixth edge portion E6. The second edge portionE2, the third edge portion E3, and the sixth edge portion E6 are regionsextending along the depth direction D2. The second edge portion E2 andthe third edge portion E3 are adjacent to each other, and the third edgeportion E3 and the sixth edge portion E6 are adjacent to each other. Thesecond edge portion E2 is located, for example, proximal to theendoscope 200 from the third edge portion E3. In that case, the sixthedge portion E6 is located distal to the endoscope 200 from the thirdedge portion E3.

On the wound W side of the second edge portion E2, an edge-end T2, whichis a cut surface caused by a tissue defect, is formed. Further, anedge-end T3, which is a cut surface generated by a tissue defect, isformed on the wound W side of the third edge portion E3. Further, anedge-end T6, which is a cut surface generated by a tissue defect, isformed on the wound W side of the sixth edge portion E6.

The first edge portion E1 and the second edge portion E2 are located soas to face each other with the wound W in between. Further, the thirdedge portion E3 and the fourth edge portion E4 are at positions facingeach other with the wound W in between. Further, the fifth edge portionE5 and the sixth edge portion E6 are located at positions facing eachother with the wound W in between.

At the peripheral edge of the wound W, the distance between theedge-ends of the facing edges is the largest between the edge-end T3 ofthe third edge portion E3 and the edge-end T4 of the fourth edge portionE4. The distance between the edge-end T1 of the first edge portion E1and the edge-end T2 of the second edge portion E2 is narrower than thedistance between the edge-end T3 of the third edge portion E3 and theedge-end T4 of the fourth edge portion E4. The distance between theedge-end T5 of the fifth edge portion E5 and the edge-end T6 of thesixth edge portion E6 is narrower than the distance between the edge-endT3 of the third edge portion E3 and the edge-end T4 of the fourth edgeportion E4.

The wound closing method according to the present embodiment includes: afirst step of connecting the first edge portion E1 and the second edgeportion E2 with the suture thread S; a second step of connecting thethird edge portion E3 and the fourth edge portion E4 with the suturethread S; and a third step of connecting the fifth edge portion E5 andthe sixth edge portion E6 with the suture thread S.

Before the first step after placing the endoscope 200, the surgeonobserves the first edge portion E1, the second edge portion E2, thethird edge portion E3, the fourth edge portion E4, the fifth edgeportion E5, and the sixth edge portion E6 of the wound W with theendoscope 200. If the surgeon determines that it is difficult to performthe first step, the surgeon performs the placement step again.

[First Step]

The first step includes: step A of passing the suture thread S through afirst position P1 on the mucosal surface of the first edge portion E1;step B of passing the suture thread S through the second edge portionE2; a first suturing step of pulling the suture thread S; and step C ofpassing the suture thread S through a second position P2 away from thefirst position P1 on the mucosal surface of the first edge portion E1.

[Step A]

In step A, the surgeon passes the suture thread S through the firstposition P1 on the mucosal surface of the first edge portion E1. Step Aincludes: step A-1 of inserting the suture needle N into the firstposition P1 on the mucosal surface of the first edge portion E1; andstep A-2 of piercing through the edge-end T1 of the first edge portionE1 with the suture needle N.

[Step A-1]

FIG. 6 is a diagram showing step A-1 in the wound closing method. FIG. 7is a cross-sectional view of the wound W orthogonal to the depthdirection D2 in step A-1. In the wound W, a mucosal layer L is removedand a submucosal layer Sm is exposed. A part of the submucosal layer Smmay be removed at the wound W. In step A-1, the surgeon rotates the gripportion 3 while gripping a rear end portion N2 of the suture needle N bythe grip portion 3, and inserts a distal end portion N1 of the sutureneedle N into the first position P1 on the mucosal surface in themucosal layer L of the first edge portion E1. In the followingdescription, the shortest distance from the first position P1 to thewound W is referred to as “shortest distance X1”.

[Step A-2]

FIG. 8 is a diagram showing step A-2 in the wound closing method. FIG. 9is a cross-sectional view of the wound W orthogonal to the depthdirection D2 in step A-2. In step A-2, the surgeon pierces through theedge-end T1 of the first edge portion E1 with the suture needle N, whichhas been inserted into the first position P1 on the mucosal surface ofthe first edge portion E1. As shown in FIG. 9 , the surgeon inserts thesuture needle N from the submucosal layer Sm at the edge-end T1. Themucosal basal layer M shown in FIG. 9 is a part of the mucosal layer Land is a layer including a boundary surface in contact with thesubmucosal layer Sm. The mucosal basal layer M may also be referred toas a basement membrane.

Specifically, in step A-2, the surgeon further rotates the grip portion3 while gripping the rear end portion N2 of the suture needle N by thegrip portion 3, and protrudes the distal end portion N1 of the sutureneedle N from the edge-end T1 of the first edge portion E1. The surgeonmay protrude the distal end portion N1 of the suture needle N from awound surface of the wound W. Next, as shown in FIG. 9 , the surgeonrotates the grip portion 3 while gripping the distal end portion N1 ofthe suture needle N protruding from the edge-end T1 with the gripportion 3, and removes the suture needle N from the edge-end T1.

[Step B]

In step B after step A, the surgeon passes the suture thread S throughthe second edge portion E2. Step B includes: step B-1 of inserting thesuture needle N into the edge-end T2 of the second edge portion E2; andstep B-2 of inserting the suture needle N from the mucosal surface ofthe second edge portion E2.

[Step B-1]

FIG. 10 is a diagram showing step B-1 in the wound closing method. FIG.11 is a cross-sectional view of the wound W orthogonal to the depthdirection D2 in step B-1. In step B-1, the surgeon rotates the gripportion 3 while gripping the rear end portion N2 of the suture needle Nby the grip portion 3, and inserts the suture needle N, which haspierced through the edge-end T1 of the first edge portion E1, into theedge-end T2 of the second edge portion E2. As shown in FIG. 11 , in stepB-1, the surgeon inserts the suture needle N into the submucosal layerSm at the edge-end T2. The surgeon may insert the suture needle N fromthe wound surface of the wound W.

[Step B-2]

FIG. 12 is a diagram showing step B-2 in the wound closing method. FIG.13 is a cross-sectional view of the wound W orthogonal to the depthdirection D2 in step B-2. In step B-2, the surgeon pierces through themucosal surface in the mucosal layer L of the second edge portion E2with the suture needle N, which has been inserted into the edge-end T2of the second edge portion E2.

Specifically, the surgeon further rotates the grip portion 3 whilegripping the rear end portion N2 of the suture needle N by the gripportion 3, and protrudes the distal end portion N1 of the suture needleN from the mucosal surface of the second edge portion E2. Next, as shownin FIG. 13 , the surgeon rotates the grip portion 3 while gripping thedistal end portion N1 of the suture needle N protruding from the secondedge portion E2 with the grip portion 3, and removes the suture needle Nfrom the second edge portion E2.

[First Suturing Step]

FIG. 14 is a diagram showing a first suturing step in the wound closingmethod.

The surgeon pulls the suture thread S in the first suturing step afterstep B. The surgeon pulls the suture thread S by the first length Z1 byretracting the grip portion 3 that grips the suture needle N, forexample. As a result, as shown in FIG. 14 , the first edge portion E1and the second edge portion E2 are close to each other.

After the first suturing step, the surgeon observes the proximity stateof the first edge portion E1 and the second edge portion E2 with theendoscope 200. If the proximity is inadequate, the surgeon performs thefirst suturing step again.

After step B, if the first edge portion E1 and the second edge portionE2 are already sufficiently close to each other, or if there is notenough space for pulling the suture thread S, the surgeon May omit thefirst suturing step.

[Step C]

In step C after the first suturing step (after step B if the firstsuturing step has not been performed), the surgeon passes the suturethread S through the second position P2 away from the first position P1on the mucosal surface of the first edge position E1. Step C includes:step C-1 of inserting the suture needle N into the second position P2 onthe mucosal surface of the first edge portion E1; and step C-2 ofpiercing through the edge-end T1 of the first edge portion E1 with thesuture needle N.

[Step C-1]

FIG. 15 is a diagram showing step C-1 in the wound closing method.

In step C-1, the surgeon inserts the suture needle N, which has piercedthrough the mucosal surface of the second edge portion E2, into thesecond position P2 on the mucosal surface in the mucosal layer L of thefirst edge portion E1 by the same method as in step A-1. In thefollowing description, the distance between the first position P1 andthe second position P2 is referred to as “first distance Y1”.

[Step C-2]

FIG. 16 is a diagram showing step C-2 in the wound closing method.

In step C-2, the surgeon inserts the suture needle N, which is insertedinto the second position P2 on the mucosal surface of the first edgeportion E1, from the edge-end T1 of the first edge portion E1 by thesame method as in step A-2.

If the suture from step A to step C is not sufficiently performed overthe depth direction D2 of the first edge portion E2 and the second edgeportion E2, the surgeon repeats steps B and C.

[Second Step]

The second step includes: step D of passing the suture thread S throughthe third position P3 on the mucosal surface of the third edge portionE3; step E of passing the suture thread S through the fourth edgeportion E4; step F of passing the suture thread S through the fourthposition P4 away from the third position P3 on the mucosal surface ofthe third edge portion E3; and a second suturing step of pulling thesuture thread S.

[Step D]

In step D after step C, the surgeon passes the suture thread S throughthe third position P3 on the mucosal surface of the third edge portionE3. Step D includes: step D-1 of inserting the suture needle N into theedge-end T3 of the third edge portion E3; and step D-2 of piercingthrough the third position P3 on the mucosal surface of the third edgeportion E3 with the suture needle N.

[Step D-1]

FIG. 17 is a diagram showing step D-1 in the wound closing method.

In step D-1, the surgeon inserts the suture needle N, which has piercedthrough the edge-end T1 of the first edge portion E1, into the edge-endT3 of the third edge portion E3 by the same method as in step B-1.

[Step D-2]

FIG. 18 is a diagram showing step D-2 in the wound closing method.

In step D-2, the surgeon pierces through the third position P3 on themucosal surface in the mucosal layer L of the third edge portion E3 withthe suture needle N, which has been inserted into the edge-end T3 of thethird edge portion E3, by the same method as in step B-2. In thefollowing description, the shortest distance from the third position P3to the wound W is referred to as “shortest distance X2”. The shortestdistance X2 is larger than the shortest distance X1 (see FIG. 6 ).

[Step E]

In step E after step D, the surgeon passes the suture thread S throughthe fourth edge portion E4. Step E includes: step E-1 of inserting thesuture needle N into the mucosal surface in the mucosal layer L of thefourth edge portion E4, and step E-2 of piercing through the edge-end T4of the fourth edge portion E4 with the suture needle N.

[Step E-1]

FIG. 19 is a diagram showing step E-1 in the wound closing method.

In step E-1, the surgeon inserts the suture needle N, which has piercedthrough the third position P3 on the mucosal surface of the third edgeportion E3, into the mucosal surface in the mucosal layer L of thefourth edge portion E4 by the same method as in step A-1.

[Step E-2]

FIG. 20 is a diagram showing step E-2 in the wound closing method.

In step E-2, the surgeon pierces through the edge-end T4 of the fourthedge portion E4 by the same method as in step A-2 with the suture needleN, which has been inserted into the mucosal surface of the fourth edgeportion E4.

[Step F]

In step F after step E, the surgeon passes the suture thread S throughthe fourth position P4 away from the third position P3 on the mucosalsurface of the third edge portion E3. Step F includes step F-1 ofinserting the suture needle N into the edge-end T3 of the third edgeportion E3, and step F-2 of inserting the suture needle N from thefourth position P4 on the mucosal surface of the third edge portion E3.

[Step F-1]

FIG. 21 is a diagram showing step F-1 in the wound closing method.

In step F-1, the surgeon inserts the suture needle N, which has piercedthrough the edge-end T4 of the fourth edge portion E4, into the edge-endT3 of the third edge portion E3 by the same method as in step B-1.

[Step F-2]

FIG. 22 is a diagram showing step F-2 in the wound closing method.

In step F-2, the surgeon pierces through the fourth position P4 on themucosal surface in the mucosal layer L of the third edge portion E3 withthe suture needle N, which has been inserted into the edge-end T3 of thethird edge portion E3, by the same method as in step B-2. In thefollowing description, the distance between the third position P3 andthe fourth position P4 will be referred to as “second distance Y2”.

[Second Suturing Step]

FIG. 23 is a diagram showing a second suturing step in the wound closingmethod.

The surgeon pulls the suture thread S in the second suturing step afterstep F. The surgeon pulls the suture thread S by a second length Z2 by,for example, retracting the grip portion 3 that grips the suture needleN. As a result, as shown in FIG. 23 , the third edge portion E3 and thefourth edge portion E4 are close to each other.

It is desirable that the second length Z2 be larger than the firstlength Z1. A portion of the wound W having a large distance in the widthdirection D1 can be sufficiently sutured by increasing the pullingamount of the suture thread S.

After the second suturing step, the surgeon observes the proximity stateof the third edge portion E3 and the fourth edge portion E4 with theendoscope 200. If the proximity is inadequate, the surgeon performs thesecond suturing step again.

After step F, when the third edge portion E3 and the fourth edge portionE4 are already sufficiently close to each other, or when there is notenough space for pulling the suture thread S, the surgeon may omit thesecond suturing step.

If the suturing from step D to step F is not sufficiently performed overthe depth direction D2 of the third edge portion E3 and the fourth edgeportion E4, the surgeon repeats step D to step F.

[Third Step]

In the third step, the fifth edge portion E5 and the sixth edge portionE6 are connected by the suture thread S by the same method as in thefirst step. The third step includes: step G of passing the suture threadS through the mucosal surface of the fifth edge portion E5 by the samemethod as in step A; step H of passing the suture thread S through thesixth edge portion E6 by the same method as in step B; a third suturingstep of pulling the suture thread S by the same method as the firstsuturing step; and step I of passing the suture thread S through themucosal surface of the fifth edge portion E5 by the same method as stepC.

Finally, the surgeon ends the procedure by tying a knot on the suturethread S. If the suture thread S has a plurality of barbs and is asuture thread S that allows movement only in the direction in which thesuture needle N is attached, a knot is not always necessary.

FIG. 24 is a diagram showing a suture thread S passed through the woundW. The suture thread S shown in FIG. 24 is not sutured. The shortestdistance X2 from the third position P3 to the wound W is larger than theshortest distance X1 from the first position P1 to the wound W. Thedistance between the edge-end T3 of the third edge portion E3 and theedge-end T4 of the fourth edge portion E4 is maximum among the distancesbetween the edge-ends of the edges facing each other on the peripheraledge of the wound W. Therefore, after closing, the force that causes thethird edge portion E3 and the fourth edge portion E4 to be separatedfrom each other becomes the largest at the peripheral edge of the woundW. However, since the shortest distance X2 is larger than the shortestdistance X1, even when the force for separating the third edge portionE3 is large, the suture thread S does not easily come off from the thirdedge portion E3.

The shortest distance X1 can also be defined as the distance in thedirection in which the suture thread S is sewn and intersects thevirtual surface V from the virtual surface V where the first facing edgeportion O1 (first edge portion E1, fourth edge portion E4, fifth edgeportion E5) and the second facing edge portion O2 (second edge portionE2, third edge portion E3, sixth edge portion E6) meet the firstposition P1. Further, the shortest distance X2 can also be defined asthe distance from the virtual surface V to the third position P3. Thegreater the distance from the virtual surface V to the position wherethe suture thread S is passed, the more difficult it is for the suturethread S to come off from the edge.

According to the wound closing method according to the presentembodiment, even a large wound W that cannot be closed by a clip can besuitably closed. The larger the defect of the wound W, the stronger theforce to separate the first facing edge portion O1 and the second facingedge portion O2 after closing. According to the wound closing methodaccording to the present embodiment, by increasing the shortest distanceX2 from the third position P3 through which the suture thread S ispassed through the third edge portion E3 where the force to be separatedis maximum to the wound W (virtual surface V), the suture thread S doesnot easily come off from the third edge portion E3. As a result, thewound closing method according to the present embodiment can suitablyclose even a large wound W.

Although the above embodiment of the present disclosure has beendescribed in detail with reference to the drawings, the specificconfiguration is not limited to this embodiment, and includes designchanges and the like within a range that does not deviate from the gistof the present disclosure. In addition, the components shown in theabove-described embodiments and modifications can be appropriatelycombined and configured.

In the wound closing method according to the above embodiment, theshortest distance X2 is larger than the shortest distance X1. However,the mode of the wound closing method is not limited to this. FIG. 25 isa diagram showing another aspect of the wound closing method of anotheraspect. It is desirable that the shortest distance X3 from the positionon the mucosal surface through which the suture thread S is passedthrough the fourth edge portion E4 to the wound W also be larger thanthe shortest distance X1 at the first edge portion E1. Even when theforce for separating the fourth edge portion E4 is large, the suturethread S does not easily come off from the fourth edge portion E4.

In the wound closing method according to the above embodiment, the firstposition P1 and the second position P2 are arranged at the first edgeportion E1, and the third position P3 and the fourth position P4 arearranged at the third edge portion E3. However, the mode of the woundclosing method is not limited to this. FIG. 26 is a diagram showinganother aspect of the wound closing method of another aspect. In thewound closing method shown in FIG. 26 , the first step includes: step Aof passing the suture thread S through the first position P1 on themucosal surface of the second edge portion E2; step B of passing thesuture thread S through the first edge portion E1; the first suturingstep of pulling the suture thread S; and step C of passing the suturethread S through a second position P2 away from the first position P1 onthe mucosal surface of the second edge portion E2. The second stepincludes: step D of passing the suture thread S through the thirdposition P3 on the mucosal surface of the fourth edge portion E4; step Eof passing the suture thread S through the third edge portion E3; step Fof passing the suture thread S through the fourth position P4 away fromthe third position P3 on the mucosal surface of the fourth edge portionE4; and the second stitching step of pulling the suture thread S. Evenin the wound closing method shown in FIG. 26 , the shortest distance X2is larger than the shortest distance X1. The second position P2 is notessential, and the suture thread S may be passed through the thirdposition P3 of the fourth edge portion after the suture thread S ispassed through the first position P1.

Further, in the modified example shown in FIG. 26 , it is desirable thatthe shortest distance X3 from the position on the mucosal surfacethrough which the suture thread S is passed through the third edgeportion E3 to the wound W also be larger than the shortest distance X1at the second edge portion E2. Even when the force for separating thethird edge portion E3 is large, the suture thread S does not easily comeoff from the third edge portion E3.

In the above embodiment, the distance from the position through whichthe suture thread S is passed to the wound W (virtual surface V) isexemplified using the first position P1 and the third position P3.However, the distance from the position where the suture thread S ispassed to the wound W (virtual surface V) is not limited to this. Thedistance from the position where the suture thread S is passed on thethird edge portion E3 or the fourth edge portion E4 to the wound W(virtual surface V) should be larger than the distance from the positionwhere the suture thread S is passed on the first edge portion E1 or thesecond edge portion E2 to the wound W (virtual surface V). This isbecause the suture thread S does not easily come off from the third edgeportion E3 and the fourth edge portion E4.

In the above embodiment, the peripheral edge of the wound W is composedof the first facing edge portion (first edge portion E1, fourth edgeportion E4, fifth edge portion E5) and the second facing edge portion O2(second edge portion E2, third edge portion E3, sixth edge portion E6).However, the aspect of the wound W is not limited to this. FIG. 27 is adiagram showing a wound W1 which is a modified example of the wound W.The peripheral edge of the wound W1 is composed of the first facing edgeportion O1 (first edge portion E1, fourth edge portion E4) and thesecond facing edge portion O2 (second edge portion E2, third edgeportion E3). In this case, the wound closing method performs the firststep and the second step in order. The third step is unnecessary becausethere are no fifth edge portion E5 and sixth edge portion E6.

FIG. 28 is a diagram showing a wound W2 which is a modified example ofthe wound W. The peripheral edge of the wound W2 is composed of thefirst facing edge portion O1 (first edge portion E1, fourth edge portionE4, first edge portion E1, fourth edge portion E4) and the second facingedge portion O2 (second edge portion E2, third edge portion E3, secondedge portion E2, third edge portion E3). In this case, in the woundclosing method, the first step and the second step are performed, andthen the first step and the second step are performed again in order.

The method for closing the wound according to another exemplaryembodiment will be described with reference to FIG. 29 . In thefollowing description, the same reference numerals will be given to theconfigurations common to those already described, and duplicatedescription will be omitted.

In the wound closing method according to the present embodiment, theshortest distance X2 does not necessarily have to be larger than theshortest distance X1 as compared with the wound closing method of theabove embodiment. On the other hand, in the wound closing methodaccording to the present embodiment, the second interval Y2 is smallerthan the first interval Y1.

FIG. 29 is a diagram showing a suture thread S passed through the woundW by the wound closing method according to the present embodiment. Thesuture thread S shown in FIG. 24 is not sutured. The first interval Y1(see FIG. 15 ) is the interval between the first position P1 and thesecond position P2. The second interval Y2 (see FIG. 22 ) is theinterval between the third position P3 and the fourth position P4.

The distance between the edge-ends of the edges facing each other on theperipheral edge of the wound W is the maximum between the edge-end T3 ofthe third edge portion E3 and the edge-end T4 of the fourth edge portionE4. Therefore, the force that causes the third edge portion E3 and thefourth edge portion E4 to be separated from each other is greatest atthe peripheral edge of the wound W. However, since the second intervalY2 is smaller than the first interval Y1, the interval at the positionwhere the suture thread S is passed through the third edge portion E3 inthe depth direction D2 (direction along the virtual surface V) of thewound W can be reduced. As a result, even when the force for separatingthe third edge portion E3 is large, the force acting on the third edgeportion E3 and the suture thread S can be dispersed.

According to the wound closing method according to the presentembodiment, even a large wound W that cannot be closed by a clip can besuitably closed. The larger the defect of the wound W, the stronger theforce to separate the first facing edge portion O1 and the second facingedge portion O2 after closing. According to the wound closing methodaccording to the present embodiment, by reducing the distance betweenthe positions where the suture thread S is passed through the third edgeportion E3 where the force to be separated is the largest, the forceacting on the third edge portion E3 and the suture thread S can bedispersed. As a result, the wound closing method according to thepresent embodiment can suitably close even a large wound W.

Although this embodiment has been described in detail with reference tothe drawings, the specific configuration is not limited to thisembodiment, and includes design changes and the like within a range thatdoes not deviate from the gist of the present disclosure. In addition,the components shown in the above-described embodiments andmodifications can be appropriately combined and configured.

In the wound closing method according to the above embodiment, thesecond interval Y2 is smaller than the first interval Y1. However, themode of the wound closing method is not limited to this. In anotheraspect of the wound closure method shown in FIG. 25 , it is desirablethat the distance Y3 between the two positions on the mucosal surfacethrough which the suture thread S is passed through the fourth edgeportion E4 also be smaller than the first distance Y1 at the first edgeportion E1. Even when the force for separating the fourth edge portionE4 is large, the force acting on the fourth edge portion E4 and thesuture thread S can be dispersed.

In the wound closing method according to the above embodiment, the firstposition P1 and the second position P2 are arranged at the first edgeportion E1, and the third position P3 and the fourth position P4 arearranged at the third edge portion E3. However, the mode of the woundclosing method is not limited to this. In another aspect of the woundclosure method shown in FIG. 26 , the first step includes: step A ofpassing the suture thread S through the first position P1 on the mucosalsurface of the second edge portion E2; step B of passing the suturethread S through the first edge portion E1; the first suturing step ofpulling the suture thread S; and step C of passing the suture thread Sthrough the second position P2 away from the first position P1 on themucosal surface of the second edge portion E2. The second step includes:step D of passing the suture thread S through the third position P3 onthe mucosal surface of the fourth edge portion E4; step E of passing thesuture thread S through the third edge portion E3; step F of passing thesuture thread S through the fourth position P4 away from the thirdposition P3 on the mucosal surface of the fourth edge portion E4; andthe second suturing step of pulling the suture thread S. Also, in thewound closing method shown in FIG. 26 , the second interval Y2 issmaller than the first interval Y1.

Further, in the modified example shown in FIG. 26 , it is desirable thatthe distance Y3 between the two positions on the mucosal surface throughwhich the suture thread S is passed through the third edge portion E3also be smaller than the first gap Y1 at the second edge portion E2.Even when the force that separates the third edge portion E3 is large,the force acting on the third edge portion E3 and the suture thread Scan be dispersed.

In the above embodiment, the distance between the positions where thesuture thread S is passed through the edge portion in the depthdirection D2 (the direction along the virtual surface V) is exemplifiedby using the first distance Y1 and the second distance Y2. However, thedistance between the positions where the suture thread S is passedthrough the edge in the depth direction D2 (direction along the virtualsurface V) is not limited to this. It is desirable that the distancebetween the positions where the suture thread S is passed through theedge in the third edge portion E3 or the fourth edge portion E4 besmaller than the distance between the positions where the suture threadS is passed through the edge in the first edge portion E1 or the secondedge portion E2. This is because the force acting on the third edgeportion E3 and the fourth edge portion E4 and the suture thread S can bedispersed.

In the above embodiment, the peripheral edge of the wound W is composedof the first facing edge portion O1 (first edge portion E1, fourth edgeportion E4, fifth edge portion E5) and the second facing edge portion O2(second edge portion E2, third edge portion E3, sixth edge portion E6).However, the aspect of the wound W is not limited to this. FIG. 30 is adiagram showing a wound W1 which is a modified example of the wound W.In the wound closing method, the first step and the second step areperformed in order. The third step is unnecessary because there are nofifth edge portion E5 and sixth edge portion E6.

FIG. 31 is a diagram showing a wound W2 which is a modified example ofthe wound W. In this case, in the wound closing method, the first stepand the second step are followed by the first step and the second stepin order.

The wound closing method according to another exemplary embodiment willbe described with reference to FIGS. 32 to 33 . In the followingdescription, the same reference numerals will be given to theconfigurations common to those already described, and duplicatedescription will be omitted.

The wound closure method according to the present embodiment further hasa reinforcement step after the third step as compared with the woundclosure method of the above embodiment described with respect to FIGS. 1to 24 . Further, in the wound closing method according to the presentembodiment, the shortest distance X2 does not necessarily have to belarger than the shortest distance X1 as compared with the wound closingmethod of the above embodiment (FIGS. 1 to 24 ).

FIG. 32 is a diagram showing the wound W after the third step. Thesuture thread S shown in FIG. 32 is sutured. In the wound closing methodaccording to the present embodiment, the reinforcement step is performedafter the third step.

[Reinforcement Step]

FIG. 33 is a diagram showing the reinforcement step.

In the reinforcement step, by using the second suture needle N2 to whichthe second suture thread S2 different from the suture thread S isattached, the surgeon passes the second suture thread S2 through thethird edge portion E3 and the fourth edge portion E4 in the same manneras in the second step. The position where the second suture thread S2 ispassed through the third edge portion E3 by the reinforcement step isbetween the positions where the suture thread S is passed through thethird edge portion E3. Further, the position where the second suturethread S2 is passed through the fourth edge portion E4 by thereinforcement step is between the positions where the suture thread S ispassed through the fourth edge portion E4. As a result, the third edgeportion E3 and the fourth edge portion E4 are connected by the secondsuture thread S2 alternately with the suture thread S.

At the third edge portion E3 or the fourth edge portion E4, the distancebetween the positions where the suture threads (suture thread S and thesecond suture thread S2) are passed through the edge portion becomessmall. The force acting on the third edge portion E3 and the fourth edgeportion E4 and the suture thread (suture thread S and second suturethread S2) can be dispersed.

According to the wound closing method according to the presentembodiment, even a large wound W that cannot be closed by a clip can besuitably closed. The larger the defect of the wound W, the stronger theforce to separate the first facing edge portion O1 and the second facingedge portion O2 after closing. According to the wound closing methodaccording to the present embodiment, by reducing the interval betweenthe positions where the suture threads (suture thread S and the secondsuture thread S) are passed through the third edge portion E3 and thefourth edge portion E4 where the force to be separated is the largest,the force acting on the third edge portion E3 and the fourth edgeportion E4 and the suture thread (suture thread S and the second suturethread S) can be dispersed. As a result, the wound closing methodaccording to the present embodiment can suitably close even a largewound W.

Although this embodiment has been described in detail with reference tothe drawings, the specific configuration is not limited to thisembodiment, and includes design changes and the like within a range thatdoes not deviate from the gist of the present disclosure. In addition,the components shown in the above-described embodiments andmodifications can be appropriately combined and configured.

In the above embodiment, the reinforcement step is performed by thesecond suture thread S2 and the second suture needle N2. However, thecorrespondence of the reinforcement step is not limited to this. FIG. 34is a diagram showing a modified example of the reinforcement step. Thereinforcement step may be performed by sandwiching the third edgeportion E3 and the fourth edge portion E4 with clips C. The force actingon the third edge portion E3 and the fourth edge portion E4 can bedispersed by the suture thread S and the clip C.

What is claimed is:
 1. A method for closing a wound in a tubular organ,comprising: a step of suturing edges at opposing positions across thewound using a first device; and a step of suturing edges where a forceto separate the wound acts greatest using a second device different fromthe first device.
 2. The method according to claim 1, wherein aperiphery of the wound includes a first edge, a second edge at aposition opposite to the first edge across the wound, a third edge at aposition adjacent to the second edge, and a fourth edge at a positionopposite to the third edge across the wound, a distance between edges ofthe wound is largest between the third edge and the fourth edge, adistance between the first edge and the second edge is smaller than adistance between the third edge and the fourth edge, the step ofsuturing edges using the first device includes a first step ofconnecting the first edge and the second edge with the first device, anda second step of connecting the third edge and the fourth edge with thefirst device, and the step of suturing edges using the second deviceincludes a reinforcing step of connecting the third edge and the fourthedge with the second device.
 3. The method according to claim 2, whereinthe second device is a clip, and the reinforcing step includesconnecting the third edge and the fourth edge with the clip.
 4. Themethod according to claim 3, wherein the first device is a suturethread, the first step includes connecting the first edge and the secondedge with the suture thread, and the second step includes connecting thethird edge and the fourth edge with the suture thread.
 5. The methodaccording to claim 2, wherein the first device is a suture thread, thesecond device is a second suture thread, the first step includesconnecting the first edge and the second edge with the suture thread,the second step includes connecting the third edge and the fourth edgewith the suture thread, and the reinforcing step includes connecting thesecond suture threads alternately with the suture threads extendingbetween the third edge and the fourth edge.
 6. The method according toclaim 4, wherein the suture thread is connected to a suture needle heldby a needle holder protruding from a distal end of an endoscope, and theconnecting of the first edge and the second edge with the suture threadincludes penetrating a tissue surrounding the wound with the sutureneedle held by the needle holder protruding from the distal end of theendoscope.
 7. The method according to claim 5, wherein the second suturethread is connected to a suture needle held by a needle holderprotruding from a distal end of an endoscope, and the connecting of thefirst edge and the second edge with the second suture thread includespenetrating a tissue surrounding the wound with the suture needle heldby the needle holder protruding from the distal end of the endoscope.